NATIONAL HEALTHCARE SAFETY NETWORK

Ventilator-Associated Event (VAE)And

Case Studies

IMPORTANT TO REMEMBER

The VAE definition algorithm is for use in surveillance; it is not a clinical definition algorithm and is not intended for use in the clinical management of patients.

KEY POINTSVAE

The VAE surveillance definition algorithm and protocol is ONLY applicable to mechanically-ventilated patient housed in adult inpatient units.

Patients who are under 18 and cared for in an adult location conducting VAE surveillance are included

Pediatric and neonatal units are excluded from VAE surveillanceVentilated patients who are 18 years of age and older and cared for

in pediatric units are included in PedVAP surveillance

KEY POINTS

VAEs are defined by a 14-day period, starting on the day of onset of worsening oxygenation. A new VAE cannot be identified or reported until this 14-day period has elapsed.

Patients on Airway Pressure Release Ventilation (APRV) are INCLUDED, but the worsening oxygenation determined by changes in the FiO2

only.

KEY POINTSSecondary BSIs may be reported for Possible

Ventilator-Associated Pneumonia (PVAP), provided that at least one organism isolated from the blood culture matches an organism isolated from an appropriate RT specimen.

Positive blood culture must be collected during the 14 day event

If you are unable to attribute a BSI secondary to VAE and a lower respiratory source of infection is thought to be the primary source of a BSI, the PNEU definitions are still available for assigning secondary BSI attribution

DEFINITIONS

VAE: Patients must be mechanically ventilated for more than 2 calendar days

to be eligible for VAE The earliest date of event for VAE is day 3 of mechanical ventilation The earliest day on which VAE criteria can be fulfilled is day 4 of

mechanical ventilation Defined by using a combination of objective criteria

Deterioration in respiratory status after a period of stability or improvement on the ventilator.

Evidence of infection or inflammation

Laboratory evidence of respiratory infection

Patient on mechanical ventilation > 2 calendar days

Baseline period of stability or improvement, followed by sustained period of worsening oxygenations

Ventilator-Associated Condition (VAC)

General, objective evidence of infection/inflammation

Infection-Related Ventilator-Associated Complication (IVAC)

Positive results of laboratory/microbiological testing

Possible VAP (PVAP)

DEFINITIONS:

Date of event (Date of onset of worsening oxygenation):The first calendar day in which the daily minimum PEEP

increases by >3 cmH2O over the daily minimum PEEP in the baseline period OR there is an increase in daily minimum FIO2 of > 20 points over the daily minimum FIO2 in the baseline period, sustained for >2 calendar days

Note: the minimum daily PEEP or FiO2 used for VAE surveillance is the lowest setting during a calendar day that was maintained for at least 1 hour.

DEFINITIONS CONT’DVAE Window Period:Period of days around the event date within

which other VAE criteria must be met.

Usually a 5 day period and includes the 2 days before, the day of, and the 2 days after the VAE event date.

There are exceptions in which the window period may only be 3 or 4 days.

DEFINITIONSEpisode of mechanical ventilation:

Period of days during which the patient was mechanically ventilated for some portion of each consecutive day

NOTE:

A break in mechanical ventilation for at least one fullcalendar day, followed by reintubation and/or reinitiating of mechanical ventilation defines a new episode of mechanical ventilation

Ask your RT department if they are collecting this information

DEFINITIONS

New antimicrobial agent:Any agent listed in the NHSN protocol that is initiated

on or after the third calendar day of mechanical ventilation AND in the VAE window period.

Considered new if it was NOT given to the patient on either of the 2 days preceding the current start date

Drugs not included: Appendix “List of Antimicrobial Agents Eligible for IVAC and PVAP”Anti-HIV, anti-TB, treat viral hepatitis, anti-parasitics

and agents used to treat herpes virus infections

DEFINITIONSQualifying Antimicrobial Day (QAD)A day on which the patient was administered an

antimicrobial agent that was determined to be “new” within the VAE Window Period. Four consecutive QADs are needed to meet the IVAC antimicrobial criterion…starting within the VAE window.

Days between administrations of a new antimicrobial agent also count as QADs as long as there is a gap of no more than 1 calendar day between administrations.

Patient has a baseline period of stability or improvement on the ventilator, defined by >2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values. (Lowest value maintained for at least 1 hour)The baseline period is defined as the two calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2

VENTILATOR-ASSOCIATED CONDITION (VAC)

After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: 1) Increase in daily minimum FiO2 of > 0.20 over the daily minimum FiO2 in

the baseline period, sustained for >2 calendar days2) Increase in daily minimum PEEP values of > 3 cmH2O over the daily

minimum PEEP in the baseline period, sustained for > 2 calendar days

AND

Patient meets criteria for VAC

INFECTION-RELATED VENTILATOR-ASSOCIATED COMPLICATION

(IVAC)

On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria:1) Temperature > 38 ºC or < 36 ºC, OR WBC >12, 000 or < 4,000

AND2) A new antimicrobial agent(s) is started and is continued for > 4 calendar days

AND

Patient meets criteria for VAC and IVAC

POSSIBLE VENTILATOR-ASSOCIATED PNEUMONIA (PVAP)

One of the following three (3) criteria is met (taking into account organism exclusions

specified in the protocol)

AND

Criterion 1:

POSSIBLE VENTIATOR-ASSOCIATED PNEUMONIA (PVAP)

1) Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol, without requirement for purulent respiratory secretions:• Endotracheal aspirate, > 105 CFU/ml or corresponding

semi-quantitative result• BAL >104 CFU/ml or corresponding semi-quantitative result• Lung tissue, >104 CFU/g or corresponding semi-

quantitative result• Protected specimen brush, >103 CFU/ml or corresponding

semi-quantitative result

POSSIBLE VENTILATOR-ASSOCIATED PNEUMONIA (PVAP)

2) Purulent respiratory secretions (from one or more specimen collections)

Defined as secretions from the lungs, bronchi, or trachea that contain > 25 neutrophils and < 10 squamous epithelial cells plus a positive culture of one of the following specimens (qualitative culture or quantitative/semi-quantitative culture without sufficient growth to meet criterion #1:

• Sputum• ET aspirate• BAL• Lung Tissue• Protected specimen brushIf the laboratory reports semi-quantitative results, those results must correspond to the above quantitative thresholds

Criterion 2:

POSSIBLE VENTILATOR-ASSOCIATED PNEUMONIA (PVAP)

3) One of the following test:• Pleural fluid culture (where specimen was obtained during

thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)

• Lung histopathology, defined as 1) abscess formation or foci of consolidation with intense neutrophil accumulation in bronchioles and alveoli; 2) evidence of lung parenchyma invasion by fung; 3) evidence of infection with viral pathogens listed below based on results of immunohistochemical assays, cytology, or microscopy performed on lung tissue

• Diagnostic test for Legionella species• Diagnostic test on respiratory secretions for influenza virus,

RSV, adenovirus, parainfluenza virus, rhiniovirus, human metapneumonovirus, coronavirus

Criterion 3:

*Excludes the following:Normal respiratory oral flora, mixed respiratory/oral flora

or equivalent

*Candida species or yeast not otherwise specific

*Coagulase-negative staphylococcus species

*Enterococcus species

The following community-associated respiratory pathogens:

Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus and Pneumocysitis

*Can be reported if isolated from cultures of lung tissue or pleural fluid

Timeline Physical findings Vent Settings

Day 1 Patient admitted to the MICU s/p cardiac and respiratory arrest. Patient intubated,has a foley catheter and central venous catheter

EXAMPLE 1

MV DAY Daily Minimum PEEP

Daily Minimum FiO2

VAE

1 8 100%

2 6 50%

3 5 40%

4 5 40%

5 6 70%

6 6 70% VAC

Timeline Physical findings Vent Settings

Day 1 Patient admitted to the MICU s/p cardiac and respiratory arrest. Patient intubated,has a foley catheter and central venous catheter

EXAMPLE 2

MV DAY Daily Minimum PEEP

Daily Minimum FiO2

VAE

1 8 100%

2 6 50%

3 5 35%

4 5 40%

5 6 70%

6 6 70%No Event

EXAMPLE 3MV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABX

1 8 100% 37.1 37.2 4.6 4.7 NO

2 6 50% 36.8 37.1 4.8 4.8 NO

3 5 50% 37.6 38 4.8 4.9 NO

4 5 40% 38.6 38.9 5.6 5.8 NO

5 6 70% 39 39 5.6 5.8 NO

6 6 70% 38.8 39 5.1 5.4 Zosyn

7 5 60% 38.0 38.1 5.2 5.4 Zosyn

8 5 70% 37.0 37.9 5.2 5.4 Zosyn

9 5 60% 37.6 37.9 4.8 5.0 Zosyn

IVACMV DAY Daily Min.

PEEPDaily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABX

1 8 100% 37.1 37.2 4.6 4.7 NO

2 6 50% 36.8 37.1 4.8 4.8 NO

3 5 50% 37.6 38 4.8 4.9 NO

4 5 40% 38.6 38.9 5.6 5.8 NO

5 6 70% 39 39 5.6 5.8 NO

6 6 70% 38.8 39 5.1 5.4 Zosyn

7 5 60% 38.0 38.1 5.2 5.4 Zosyn

8 5 70% 37.0 37.9 5.2 5.4 Zosyn

9 5 60% 37.6 37.9 4.8 5.0 Zosyn

EXAMPLE 4MV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABXSpecimen

Polys/Epis

Organism

1 8 100% 37.1 37.2 4.6 4.7 NO

2 6 50% 36.8 37.1 4.8 4.8 NO

3 5 50% 37.6 38 4.8 4.9 NO

4 5 40% 38.6 38.9 5.6 5.8 NO

5 6 70% 39 39 5.6 5.8 NO

6 6 70% 38.8 39 5.1 5.4 Zosyn ETA < 10 sq

>25 polys

S. aureus

7 5 60% 38.0 38.1 5.2 5.4 Zosyn

8 5 70% 37.0 37.9 5.2 5.4 Zosyn

9 5 60% 37.6 37.9 4.8 5.0 Zosyn

POSSIBLE VAPMV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABXSpecimen

Polys/Epis

Organism

1 8 100% 37.1 37.2 4.6 4.7 NO

2 6 50% 36.8 37.1 4.8 4.8 NO

3 5 50% 37.6 38 4.8 4.9 NO

4 5 40% 38.6 38.9 5.6 5.8 NO

5 6 70% 39 39 5.6 5.8 NO

6 6 70% 38.8 39 5.1 5.4 Zosyn ETA < 10 sq

>25 polys

S. aureus

7 5 60% 38.0 38.1 5.2 5.4 Zosyn

8 5 70% 37.0 37.9 5.2 5.4 Zosyn

9 5 60% 37.6 37.9 4.8 5.0 Zosyn

VAE NUMBER 1

When should I use PNEU/VAP instead of VAE?1. Never—always use VAE2. When surveillance is to be conducted in mechanically

ventilated children who are in pediatric locations3. When surveillance is to be conducted for healthcare-

associated pneumonia that is not associated with mechanical ventilation

4. 2 and 3

5. None of the above

VAE NUMBER 2

When evaluating patient data to see if the IVAC definition is met, I should focus only on antibiotics that are used to treat respiratory infections

1. Yes2. No

VAE NUMBER 3

When selecting the daily minimum PEEP and FiO2 for each calendar day…..

1. Throw out the lowest value2. Choose the most consistent value3. Select the value using any 24 hour time period4. Choose the lowest value that has been

maintained for at least 1 hour

CASE STUDY

A 72 year old male is seen in the ED on January 1st, following a MVA. He sustained closed rib fractures, ruptured spleen and dissection of the aorta.

In the ED central lines and a Foley catheter were placed. He was admitted to the Trauma ICU on that same day where he was intubated and stabilized at a PEEP setting of 6 cm H2O and FiO2 of 50%

On MV Day 4 he required an increase in PEEP to 7.5 cm H2O and FiO2 to 80%

Utilize the information on the table to evaluate for VAE

MV DAY Daily Minimum PEEP

Daily Minimum FiO2

VAE

1 6 .50

2 6 .50

3 6 .50

4 7.5 .80

5 7.5 .80

6 7.5 .75

7 6 .75

8 6 .75

9 6 .60

10 8 .80

11 8 .80

12 6 .60

13 6 .60

14 6 .60

CRITERIA FOR VAC MET?

A. Yes

B. No

WHAT DATE

A. Day 5B. Day 6C. Day 4D. Day 3

MV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABXSpecimen

Polys/Epis

Organism

1 6 .50 N

2 6 .50 N

3 6 .50 N

4 7.5 .80 36.5 37.3 7.2 9.2 N

5 7.5 .80 36.3 38.9 7.4 8.4 N BAL >25/<10

104 Kleb. p

6 7.5 .75 37.3 38.5 8.5 8.8 Y

7 6 .75 Y

8 6 .75 Y Blood Kleb. pneu

9 6 .60 Y

10 8 .80 Y

11 8 .80 Y

12 6 .60 Y

13 6 .60 Y

14 6 .85 Y

WHAT DO YOU THINK?

A. IVAC MV Day 4

B. Possible VAP MV Day 4

C. Possible VAP Day 4 and VAC MV Day 14

D. Probable VAP MV Day 4

DOES THIS PATIENT DEVELOP A SECONDARY BLOODSTREAM INFECTION?

A. Yes

B. No

CASE STUDY 2

A 56 year old male is taken directly to the OR from the Cath Lab following arrest during angioplasty procedure

Quadruple bypass procedure is preformed and he remains on the ventilator following surgery (MV day 1). He has a central line and a foley catheter in place when he arrives in the ICU that same day

MV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABXSpecimen

Polys/Epis

Organism

1 6 30 37.1 37.6 4.3 4.3 N

2 6 30 36.8 37.2 4.6 4.6 N

3 6 30 37 37.9 5.4 5.4 N

4 8 30 36.5 37.3 7.2 9.2 N

5 8 30 36.3 37.3 7.4 12.5 N BAL 10.4 Enterococcus

6 8 50 37.2 37.9 8.5 13.0 Y

7 6 50 37.3 37.8 ND Y BC x2 Enterococcus

8 6 40 37.3 37.9 ND Y

9 6 40 37.5 37.9 9.7 Y

10 8 40 37.4 37.6 9.6 Y

11 8 40 37.2 37.9 9.4 Y

12 6 30 37.3 37.5 9.5 N

13 6 30 37.4 37.6 8.2 N

14 6 60 37.2 37.7 13.0 Y

IDENTIFY THE EVENTS FOR THIS PATIENT

A. MV Day 6…IVAC with primary BSIB. MV Day 6 – Possible VAP with

secondary BSIC. MV Day 14 – IVACD. MV Day 14 – Probable VAP

CASE STUDY 342 year old female dialysis patient was intubated and

transferred from Hospital A to Hospital B on MV Day 1 for management of severe asthma exacerbations

The patient had been receiving vancomycin for treatment of BSI

Upon admission her temperature was 37.5 C and WBC 5.6

On MV day 3 during dialysis treatment the patient developed a temperature of 39.7 C

On MV day 5 she had increased respiratory secretions and an ET aspirate was sent for culture and GS

On MV Day 7 imipenem was started

MV DAY

Daily Min.PEEP

Daily Min. FiO2

TempMin

TempMax

WBCMin

WBC Max

ABXSpecimen

Polys/Epis

Organism

1 6 50 37.1 37.5 4.3 5.6 Vanc

2 5 40 37 37.2 N

3 6 40 37.2 39.9 Vanc

4 6 60 37.9 39.3 N

5 6 60 36.3 39.3 Vanc ETA >25/<10

Heavy Kpneumoniae

6 6 60 37.2 39.9 N

7 6 60 37.3 37.8 Imp

8 5 60 37.3 37.9 Imp

9 5 55 38 38 Imp

10 6 60 37.4 37.9 Imp

PATIENT HAS:SELECT THE BEST RESPONSE

A. VACB. IVACC. Possible VAPD. No VAE

CASE STUDY 4

A 69-year old female is seen in the ER with an admitting diagnosis of community acquired pneumonia (CAP). She is admitted to the ICU the same day on a ventilator. Review her ventilator settings and determine if VAE criteria are met.

MV Day Daily minimum Peep Daily minimum FIO2

1 8 100

2 6 50

3 5 50

4 6 40

5 6 70

6 6 70

7 5 60

8 5 70

9 5 60

1.Yes2.No

MV Day

Daily Min Peep

Daily Min FIO2

Temp WBC ABX ABX Specimen

Polys/Epi

Organism

1 8 100 38.0 Pip/Taz

2 6 50 39.0 Pip/Taz

sputum Scant NF, Many S. aureus

3 5 50 37.6 4.9 Pip/Taz

VancoIV

4 6 40 38.6 5.8

5 6 70 39 5.8 Vanco IV

6 6 70 38.8 5.4 BAL >104cfu/ml S. aureus

7 5 60 38.0 5.4 VancoIV

8 5 70

9 5 60 VancoIV

CASE STUDY 4 CONT’D

What specific event should be reported for this patient?1. None, the patient had CAP present on admission2. Possible VAP (Pathogen SA)3. Probable VAP (Pathogen SA)4. VAC only

WE DIDIT!!!GOOD JOB!!!